Provider Demographics
NPI:1013630334
Name:SMITH, DEWAYNE JR
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 W CHARLESTON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2258
Mailing Address - Country:US
Mailing Address - Phone:702-235-7455
Mailing Address - Fax:
Practice Address - Street 1:2055 W CHARLESTON BLVD STE C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2258
Practice Address - Country:US
Practice Address - Phone:702-235-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBACB838822OtherBACB